Introduction

Gastric bezoars are concretions of foreign material in the gastric lumen. The incidence of gastric bezoars is very low (around 0.4% [1, 2]) and they are of varied composition.

There is a classification of bezoars according to composition: - phytobezoars are composed of vegetable matter and are the most common type,- trichobezoars are composed of hair, - and pharmacobezoars are composed of ingested medications.

An especially rare type of bezoar caused by persimmons has recently been described – disopyrobezoar - these are considered to be harder than any other types of gastric bezoars.

There are several possible pathological situations in which gastric bezoars can occur, since they are not common in healthy people - these include surgical procedures, systemic pathology that causes delayed gastric emptying such as diabetes mellitus, mixed connective tissue disease, and hypothyroidism.

Phytobezoars are more common in male patients, whereas tricobezoars are more common in females.

Traditionally, gastric bezoars were treated surgically; nowadays their management is preferentially conservative. Treatments include chemical dissolution, endoscopy or gastric suction. A surgical approach is considered only when conservative treatment fails.

Lavage with Coca-Cola® as a safe and effective treatment for gastric bezoars was first described in 2002 [1]. Since then few reports have been published on the matter. Here we present a case of successful treatment with Coca-Cola® oral intake.

Case report

A 64-year-old woman was received in February 2007 at the Hospital Universitario Marqués de Valdecilla (H.U.M.V.). Gastrointestinal symptoms were hypogastric abdominal pain and gastric fullness for 3 to 4 years. Pain intensified when standing and decreased when lying down. She also presented with perineal pain which was initially related to a cystocoele grade 3.

The patient's medical history included allergy to acetylsalicilyc acid, diabetes mellitus type II, and hyperthyroidisim. She was also a smoker.

Her habitual medications were Idaptan®, Sumial®, Omeprazol®, plus oral antidiabetic agents, and Thirodril® for her hyperthyroidism.

The patient underwent surgery for cystocoele grade 3 and for urinary incontinence. She experienced no improvement in her symptoms.

Several studies were arranged in order to rule-out malignant disease. Tumor markers were normal, as was nutritional analysis.

An abdominal CT-scan showed a circular mass of approximately 20cm diameter inside the stomach (Fig 1).

Figure 1 CT scan image showing huge gastric bezoar.

In the same month, an endoscopy was performed in which a large bezoar was detected. It was impossible for the endoscopist to break it into pieces and remove it safely, so surgical treatment was planned. Meanwhile, treatment with Coca-Cola® was started based on the procedure described by Ladas et al. [2].

The patient was asked to drink 3 cans of Coca-Cola® per day with every meal (33 cl. 3 times a day) for a month. However, initial symptoms did not clearly disappear and a surgical treatment was scheduled.

The operation was performed 1 month after the diagnosis of the gastric bezoar. A standard laparotomy was carried out finding a morphologically-normal stomach without distension or wall thickness. The pylorus had neither a stricture nor other signs of ulcerative disease. Gastric content was revealed by gastrotomy. No bezoar was found, but some vegetable residue remained.

We concluded that Coca-Cola® oral intake had been effective for dissolving the gastric bezoar.

Postoperative development was acceptable with an isolated fever peak on the 4th postoperative day without additional clinical impact. The patient was discharged 6 days after surgery. No recommendation on continuing Coca-Cola® intake was given as there is no clinical evidence in the literature as to its benefit.

The patient remained asymptomatic during the 4-month follow-up period.

Discussion

Our clinical report adds further information about Coca-Cola® based treatment as an effective non-aggressive treatment for gastric bezoars. Few reports on this subject are currently found in the literature. In previous reports Coca-Cola® was administered by infusion through a nasogastric tube or by direct endoscopic injection [2,3]. In this case, however, the treatment consisted of Coca-Cola® oral intake with no need for nasogastric tube insertion.

Mechanical and chemical procedures are used in the treatment of gastric bezoars. Bezoars can be broken into pieces using endoscopic forceps, polypectomy snares, Dormia baskets, endoscopic lithotripsy, YAG laser or electrosurgical knives. These techniques require specific equipment which may not be available and and are not harmless procedures. Several complications such as bleeding, perforation or even migration of bezoar pieces causing intestinal obstruction. [2-4] can result.

Medical treatment may also be useful. Several chemical agents have been tested, these are administered orally, through a nasogastric tube or directly injected into the bezoar mass by endoscopy. However, the development of these techniques usually takes time, is not free of potential complications (electrolytic disorders, gastric ulcer) and has an unclear outcome [10].

The mechanism of Coca-Cola® dissolution is not fully explained. Phosphoric acid (H3PO4) is a component of Coca-Cola® and is responsible for its pH of 2.6, which is close to the pH of gastric secretions. It has been suggested that this acidification of the gastric content may be the way Coca-Cola® acts by disintegrating the bezoar. The release of carbon dioxide (CO2) bubbles into the gastric lumen and the mucolitic action of sodium bicarbonate (NaHCO3) may also contribute to bezoar dissolution [1,10].

We report a case of a large gastric bezoar being successfully treated with oral Coca-Cola® intake. This is an easy, safe and effective procedure with no need for invasive techniques nor hospital stay, and many patients would surely benefit from this approach. Continuous Coca-Cola® intake after bezoar dissolution has not as yet proved to be effective; further studies should be needed to clarify this subject.